HIV Risk Behaviors Among Substance-Using Populations

The intersection of substance use and HIV transmission is driven by a confluence of biological, behavioural and structural factors. Injecting drug use remains a primary route of bloodborne HIV transmission where sharing of needles, syringes and other injecting equipment persists despite widespread availability of sterile-injecting programmes. Concurrently, non-injecting psychoactive substance use can impair judgment and reduce condom use, leading to increased sexual exposure. Transactional sex—exchange of sex for money, drugs or shelter—frequently accompanies substance dependence and amplifies vulnerability through multiple or transient partnerships and inconsistent prevention practices. Underlying these behaviours are broader determinants such as homelessness, poverty, stigma and criminalisation of drug use, which hinder access to prevention and care. Integrated approaches that combine harm reduction (including needle and syringe programmes), sexual health services, mental health support and social-protection measures have shown promise in curbing new infections. Biomedical prevention with pre-exposure prophylaxis has been under-utilised among people who use drugs, while post-exposure prophylaxis is often delayed or inaccessible outside clinical settings. Global experience—from Eastern Europe to sub-Saharan Africa—underscores the need for community-driven, low-threshold interventions that address both injecting and sexual risk in diverse substance-using populations.

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HIV Risk Behaviors Among Substance-Using Populations publication trend

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Technical terms

Transactional sex: Exchange of sexual services for money, drugs, goods or shelter, often heightening HIV exposure due to power imbalances and inconsistent condom use.

Polysubstance use: Concurrent or sequential consumption of two or more psychoactive substances, which may amplify risk behaviours and complicate prevention efforts.

Structural vulnerability: Exposure to social, economic and legal conditions—such as homelessness, poverty and criminalisation—that increase susceptibility to HIV and impede access to services.

Pre-exposure prophylaxis (PrEP): Regular use of antiretroviral medication by HIV-negative individuals to prevent acquisition of the virus before potential exposure.

Syringe services programme: Community-based initiatives providing sterile injecting equipment, safe disposal, overdose prevention and linkage to health and social services.

References

1. Selling sex in the context of substance use: social and structural drivers of transactional sex among men who use opioids in Maryland. Harm Reduction Journal (2022).
2. Latent Classes of Polysubstance Use and Associations with HIV Risk and Structural Vulnerabilities among Cisgender Women Who Engage in Street-Based Transactional Sex in Baltimore City. International Journal of Environmental Research and Public Health (2022).
3. Characterization of Patients Seeking Care at a Sexual Health Clinic Who Report Engaging in Exchange Sex. Sexually Transmitted Diseases (2022).